Comparison of visibility in needle arthroscopy of the ankle according to surgical experience: A cadaveric study.

BACKGROUND: Literature regarding the feasibility of inexperienced surgeons using needle arthroscopy is limited. The present study aimed to clarify the feasibility of performing ankle needle arthroscopy for inexperienced surgeons. METHODS: Diagnostic needle arthroscopy was performed for 10 cadaveric ankles by two surgeons with different levels of experience in ankle arthroscopy (inexperienced and expert surgeons). The visibility of arthroscopy was assessed based on a 15-point checklist and compared between surgeons. In addition, iatrogenic articular cartilage injury created by the inexperienced surgeon was investigated. RESULTS: The number of visible points was significantly larger for the expert surgeon than for the inexperienced surgeon (14.1 ± 1.0 vs. 13.7 ± 1.0, P = 0.035). The location of cartilage injury was greatest on the medial talar dome when viewing from the anteromedial portal at a rate of 30%. CONCLUSION: Ankle needle arthroscopy may be an option for surgeons in the future, however, differences in surgeon experience may impact effective visualization.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon.

BACKGROUND: The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture. METHODS: A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up. RESULTS: Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up (P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively (P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery. CONCLUSION: The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare.

PURPOSE: To elucidate surgical outcomes in pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare. METHODS: A retrospective chart review was conducted of pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare following simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active range of motion exercises for the ankle in our department between 2013 and 2017. Clinical outcomes were evaluated by comparing preoperative and final follow-up American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and Karlsson-Peterson ankle function scores. Intervals between surgery and return to physical education in school were determined. RESULTS: 31 feet of 15 male and 16 female patients were examined. Mean postoperative follow-up duration was 40.7 ± 12.7 (range 24-66) months. Mean AOFAS score increased significantly from 66.3 ± 2.5 (range 62-77) preoperatively to 96.5 ± 4.9 (range 87-100) at final follow-up (p < 0.001). Mean Karlsson-Peterson score increased significantly from 51.7 ± 4.0 (range 47-70) preoperatively to 95.3 ± 6.7 (range 80-100) at final follow-up (p < 0.001). Mean interval between surgery and return to physical education in school was 11.4 ± 1.6 (range 10-18) weeks. CONCLUSION: Simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active ankle range of motion exercises may give excellent clinical outcomes with early return to physical activity for chronic lateral ankle instability with os subfibulare in pediatric/adolescent patients desiring an early return to physical activity. Level of evidence III.

Clinical outcomes and protocol for the management of isolated congenital diaphragmatic hernia based on our prenatal risk stratification system.

BACKGROUND/PURPOSE: The aim of this study was to evaluate our prenatal risk stratification system for risk-adjusted management in fetuses with isolated congenital diaphragmatic hernia (CDH). METHODS: Ninety-four infants prenatally diagnosed with isolated CDH treated between 1998 and 2017 at our institution were included in this retrospective single-center cohort study. RESULTS: The patients were prenatally classified into four risk groups: Group A (n = 54), which consisted of infants with neither liver-up nor a contralateral lung-to-thorax transverse area (L/T) ratio <0.08. The infants in group A were divided into two subgroups: Group A-1 (n = 24) consisted of mild conditions; and Group A-2 (n = 30) consisted of severe conditions; Group B (n = 23), which consisted of infants with either liver-up or L/T ratio <0.08; and Group C (n = 17), which consisted of infants with both liver-up and L/T ratio <0.08. The rates of survival to discharge in Groups A-1, A-2, B, and C were 100.0%, 100.0%, 87.0%, and 58.8%, respectively. The rates of intact discharge were 91.7%, 90.0%, 52.1%, and 23.5%, respectively. CONCLUSIONS: Our prenatal risk stratification system demonstrated a significant difference in the severity of postnatal status and clinical outcomes between the groups. STUDY TYPE: Case Series, Retrospective Review. LEVELS OF EVIDENCE: LEVEL IV.

Prenatally diagnosed congenital hemangioma with elevated middle cerebral artery peak systolic velocity mimicking the Kasabach-Merritt phenomenon: A case report.

Congenital hemangioma is a rare vascular tumor that develops prenatally, and a large congenital hemangioma may be accompanied by the Kasabach-Merritt phenomenon. We present a case of prenatally diagnosed fetal congenital hemangioma through ultrasound and maternal anti-Jr(a) antibody alloimmunization with elevated middle cerebral artery peak systolic velocity. To investigate fetal anemia and hemostatic condition, we performed percutaneous umbilical blood sampling, which revealed no symptom of either Kasabach-Merritt phenomenon or sensitization to anti-Jr(a) antibody. Consequently, pregnancy could be continued without further intervention. After birth, congenital hemangioma was found on the infant's left thigh, and Kasabach-Merritt phenomenon was not shown. Percutaneous umbilical blood sampling could provide precise information prenatally in case of congenital hemangioma with maternal alloimmunization.

Clinical outcomes of ex utero intrapartum treatment for fetal airway obstruction.

PURPOSE: The aim of this study was to evaluate the indications and the clinical outcomes of the fetuses managed with ex utero intrapartum treatment (EXIT) procedures. METHODS: We retrospectively reviewed the medical records of all fetuses who underwent EXIT procedures between 2003 and 2018. RESULTS: EXIT procedures were performed in nine cases. The prenatal diagnosis of the neonates was congenital high airway obstruction syndrome in four cases, the neck masse in five cases. Although the airway management under the EXIT procedure was successful in eight cases, the airway management failed in one case. During the EXIT procedures, the airway was managed by endotracheal intubation in two cases, whereas six cases underwent tracheostomy. Six cases with fetal airway obstruction survived to discharge, whereas three cases died due to airway management failure or complications of the underlying disease. A case with a cervical teratoma underwent tumor resection the day after birth due to rapid enlargement of the neck mass. Long-term survival was achieved in five cases. CONCLUSIONS: We concluded that the EXIT procedure was effective and could be performed safely in the airway management of fetuses with suspected airway obstruction. The treatment strategy for the neck masses should be planned before birth.

Real prevalence of neural tube defects in Japan: How many of such pregnancies have been terminated?

The vital role of folic acid is to reduce the risk of having a neonate afflicted with neural tube defects. The prevalence of neural tube defects (myelomeningocele and anencephaly) has been reported in an incomplete form over the last 40 years in Japan. We aimed to evaluate the total number of neural tube defects including those delivered or terminated, to clarify the proportion of those terminated, and to internationally compare their prevalence. Through information on >311 000 deliveries obtained from 262 hospitals/clinics for 2 years of 2014 and 2015, we identified that the rate of total neural tube defects (termination of pregnancy, live births and stillbirths) was 8.29 per 10 000 deliveries for the year 2014 and was 8.72 for 2015, which were 1.5 and 1.6 times higher than the respective values (live births and stillbirths) reported. It is also observed that the ratio of the total number of myelomeningocele (termination of pregnancy, live births, and stillbirths) to that of anencephaly was approximately 1:1.2, that a half of pregnancies afflicted with neural tube defects were terminated, and that the proportion of termination of pregnancy due to myelomeningocele and due to anencephaly was 20% and 80%, respectively. Internationally, the real prevalence of neural tube defects in Japan was comparatively high, ranking fifth among the seven developed countries. In conclusion, the real prevalence of total neural tube defects was approximately 1.5 times higher than that currently reported by the Japan Association of Obstetricians and Gynecologists.

Prenatal risk stratification of severe small-for-gestational-age infants: a Japanese multicenter study.

OBJECTIVE: To establish a prenatal prognostic classification of severe small-for-gestational-age (SGA) infants based on gestational age and fetal findings. METHODS: A retrospective cohort study of 366 singleton infants (birth weight <3rd percentile) delivered between 22 and 34 weeks' gestation at nine tertiary perinatal centers. A decision tree model was developed for the prediction of death or severe morbidity. RESULTS: There were 35 infants with poor outcome. Prematurity was the most powerful factor in those born before 27.9 weeks' gestation, while oligohydramnios was the most powerful factor in those born at 27.9 weeks or after. The rate of poor outcome in infants born before 25.1 weeks, between 25.1 and 27.9 weeks, at 27.9 weeks or after with oligohydramnios, at 27.9 weeks or after without oligohydramnios, was 53.9%, 18.2%, 13.6% and 3.2%, respectively. CONCLUSIONS: Risk stratification based on gestation of 25 weeks, 28 weeks and oligohydramnios may aid in prognosis of severe SGA infants.

Postnatal outcome in cases of prenatally diagnosed fetal ovarian cysts under conservative prenatal management.

AIM: To evaluate the outcome of cases of prenatally diagnosed fetal ovarian cyst under conservative prenatal management. METHODS: This retrospective cohort study included patients diagnosed between January 2005 and August 2013. They were managed expectantly during pregnancy and followed up until spontaneous regression of the cyst or postnatal surgery. The outcomes of fetal ovarian cysts were compared combined appearance as being simple or complex at prenatal scan and maximum size of cysts ≥ 40 or <40 mm. RESULTS: There were 33 study cases. Prenatally 3/33 cases (9%) had spontaneous cyst regression during pregnancy. 14 cysts (42%) were treated surgically, of which torsion was confirmed in 4 (29%). Another 14/33 cases (42%) regressed spontaneously under conservative management after birth. The ovaries could be preserved in 28 patients (85%). The incidence of torsion between complex cysts and simple cysts was not statistically different. The incidence of torsion between patients with cyst size ≥ 40 and <40 mm was similar. CONCLUSIONS: The ovaries could be preserved in approximately 85% of patients under conservative management. The present study could not reveal the significance of prenatal ultrasonographic findings of fetal ovarian cyst for predicting the outcome of patients' ovaries.

In utero resolution of microcystic congenital cystic adenomatoid malformation after prenatal betamethasone therapy: A report of three cases and a literature review.

Fetal congenital cystic adenomatoid malformation (CCAM) can progress to nonimmune hydrops, and the mortality rate of CCAM with hydrops is reported to be nearly 100%. We describe three microcystic CCAM cases in which the fetal condition improved after maternal betamethasone therapy. The median gestational age at steroid administration was 23 5/7 weeks' gestation. The CCAM decreased in size in all cases. Our series showed a 100% hydrops resolution rate (2/2) and a 100% survival rate (3/3). Our experience suggests the efficacy of betamethasone treatment on fetuses with microcystic CCAM who have fluid collection or are at risk of developing hydrops.

Partial harvesting technique in anterior cruciate ligament reconstruction with autologous semitendinosus tendon to prevent a postoperative decrease in deep knee flexion torque.

BACKGROUND: A significant decrease in deep knee flexion torque has been reported after harvesting the semitendinosus tendon for anterior cruciate ligament (ACL) reconstruction. Thus, we have developed a partial harvesting technique that leaves part of the width of the insertion of semitendinosus tendon by splitting it. Our hypothesis was that the partial harvesting technique would reduce postoperative functional deficits in deep knee flexion by achieving regeneration of harvested tendon without shortening. METHODS: A total of 36 patients who underwent ACL reconstruction with an autologous semitendinosus tendon by means of either the conventional whole harvesting technique (whole-ST group, n=16) or the partial harvesting technique (partial-ST group, n=20) were included in this study. Clinical outcome, semitendinosus muscle length, and deep knee flexion torque were assessed 2 years after surgery. RESULTS: No significant group differences were found in terms of range of motion, Lysholm score, or anterior knee laxity. Shortening of the semitendinosus muscle was significantly less in the partial-ST group (mean 8mm) than in the whole-ST group (mean 36 mm; P<0.001). The side-to-side ratio of isometric knee flexion torque in the prone position with 90° of knee flexion was statistically different between the partial-ST (87.0 ± 20.4%) and whole-ST (55.3 ± 13.9%; P<0.001) groups. CONCLUSIONS: The present partial harvesting technique not only prevented shortening of the semitendinosus muscle, but also reduced the deficit in the maximum knee flexion angle in the standing position and a decrease in the deep knee flexion torque in the prone position with the partial harvesting technique compared to the nonoperated side with good clinical outcomes. LEVEL OF EVIDENCE: Case-control study, Level III.

Laser therapy for twin-twin transfusion syndrome in the absence of fetoscopically visible placental vascular anastomoses.

Fetoscopic laser photocoagulation (FLP) was performed at 22 weeks of gestation for a pregnancy complicated with twin-twin transfusion syndrome (TTTS) and an anterior placenta. However, vascular anastomoses could not be identified by the fetoscope. To dichotomize the circulation between the twins, the terminal ends of the paired artery and vein of the recipient twin were coagulated. In addition, a line was drawn with the laser connecting the dots, which had been coagulated. The Doppler waveform as well as the amniotic fluid volume of each twin normalized after the procedure. The twins were delivered by cesarean section subsequent to onset of labor at gestational week 30; the recipient twin weighed 1,350 g and the donor twin weighed 550 g. Both twins had a normal neurologic exam at 6 months of age. Patent placental vascular anastomoses could not be detected. This case demonstrates that vascular anastomoses in TTTS may not be identified by a fetoscope and that FLP to coagulate the entire vascular equator closer to the area of the recipient twin was effective in this rare situation.

Immunoregulatory gene polymorphisms in Japanese women with preterm births and periodontitis.

Many studies have reported an association between periodontal disease and preterm birth, although this remains controversial. Cytokines and antibodies produced to give resistance to infection can enter the bloodstream and cause preterm labor. We analyzed maternal genetic polymorphisms in various immunoregulatory genes that could affect both preterm birth and periodontitis. A total of 1099 women referred to the Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital were candidates for participation, 424 of whom refused, and 553 were excluded. The final number of subjects was 122 (51 with preterm birth, 71 with term birth). Genomic DNA was isolated from venous blood, and 22 polymorphisms were determined: IL-1A, IL-1B, IL-1RN, IL-2, IL-4, IL-6, IL-10, TNFA, TNFRI, TNFRII, FcγRIIA, FcγRIIB, FcγRIIIA, FcγRIIIB, and FcαR. Within five days of labor, periodontal parameters were evaluated, and bacteria from subgingival plaque were detected using real-time PCR. There was no difference in the prevalence and degree of periodontitis between term and preterm births. Chi-squared tests showed that an age <33 years and FcαR(+56)T/C alleles were associated with preterm birth. Multiple logistic regression analysis represented a model with significant fitness in which four variables were associated with preterm birth: maternal age, number of Aggregatibacter actinomycetemcomitans, IL-6(-572)G/C, and FcαR(+56)T/C. In conclusion, there was no association between preterm birth and periodontitis in this study. A. actinomycetemcomitans, IL-6, and FcαR were suggested to be associated with preterm birth. Multiple logistic regression models with both genetic and environmental factors would be useful for evaluating susceptibility to preterm birth.

The association of Aggregatibacter actinomycetemcomitans with preeclampsia in a subset of Japanese pregnant women.

AIM: To determine whether periodontitis and three prominent members of the periodontal flora are associated with the development of preeclampsia (hypertension plus proteinuria) Materials and Methods: The samples were composed of 127 systemically healthy women. Within 5 days after labour, clinical periodontal parameters and Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia in subgingival plaque were evaluated. Maternal serum IgG antibody specific for each bacteria was determined by enzyme-linked immunosorbent assay. Multivariate logistic regression analysis was used to control for confounders (maternal age, body mass index before pregnancy, parity, and smoking). RESULTS: Eighteen women were affected with preeclampsia. The number of A.actinomycetemcomitans was shown to be significantly associated with preeclampsia in the logistic regression model (odds ratio; 1.7, 95% confidence interval; 1.1­2.7). There were statistically significant differences between the preeclamptic and control groups in body mass index before pregnancy, pre-term birth and low birthweight (respectively, p = 0.014, p = 0.010 and p < 0.0001). We found no statistically significant association between preeclampsia and periodontal clinical parameters or the presence of periodontitis. CONCLUSION: In systemically healthy pregnant women, our findings suggested that the levels of maternal subgingival A. actinomycetemcomitans DNA were elevated in preeclamptic women.

Functional treatment after surgical repair for acute lateral ligament disruption of the ankle in athletes.

BACKGROUND: There have been several reports showing 20% to 40% failure after nonoperative functional treatment for acute lateral ligament disruption of the ankle. HYPOTHESIS: Functional treatment after primary surgical repair has the advantage of decreasing the failure rate in comparison with functional treatment alone. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 132 feet of 132 patients were included in this study. Of these, 78 patients were treated with functional treatment alone (group F), and the remaining 54 patients were treated with functional treatment after primary surgical repair (group RF). The clinical results were evaluated using the Japanese Society for Surgery of the Foot Ankle-Hindfoot scale (JSSF) score, measuring the talar tilt angle and the anterior displacement of the talus in stress radiography, and noting the elapsed time between the injury and the return to the full athletic activity with no external supports. RESULTS: The mean JSSF scores at 2 years after injury were 95.6 ± 5.0 points in group F and 97.5 ± 2.6 points in group RF (P = .0669). The differences of the talar tilt angles compared with the contralateral side and displacement of the talus on stress radiography at 2 years after injury were 1.1° ± 1.5° and 3.6 ± 1.6 mm in group F, and 0.8° ± 0.9° and 3.2 ± 0.8 mm in group RF, respectively (P = .4093, .1883). In group F, 8 cases showed fair to poor results, with JSSF scores below 80 points and instability at 2 years after injury. In group RF, 9 cases (9.4%) showed dorsum foot pain along the superficial peroneal nerve, which disappeared within a month. The time elapsed between the injury and the patient's return to full athletic activity without any external supports was 16.0 ± 5.6 weeks in group F and 10.1 ± 1.8 weeks in group RF (P < .0001). CONCLUSION: Nonoperative functional treatment alone and functional treatment after primary surgical repair showed similar overall results after acute lateral ankle sprain, but functional treatment alone had an approximately 10% failure rate and a slower return to full athletic activity. The authors recommend that treatment be tailored to suit each individual athlete.

No changes in infliximab levels in blood stored for preoperative autologous blood donation.

Rheumatoid arthritis (RA) patients requiring total joint arthroplasties under administration of infliximab, which may remain in donated blood if preoperative autologous blood donation (PABD) is undertaken for the surgery, may risk infection. We clarified infliximab hemokinetics in blood stored for such patients. A 20-ml blood sample was obtained from each of the ten RA patients receiving infliximab at just after administration and at 2 and 4 weeks following the administration of infliximab, mixed with 2.8 ml citrate-phosphate-dextrose-adenine (CPDA-1) and stored at 4-6 degrees C. Plasma levels of infliximab in the stored blood were measured just after-mixture with CPDA-1, and at 2 and 4 weeks following the start of storage. Serum levels were also measured just before infliximab administration and at each phlebotomy. The plasma infliximab levels in the stored blood remained close to their original serum levels at the time of each corresponding phlebotomy, only somewhat influenced by dilution of CPDA-1, and sustained for 4 weeks following the start of storage, unlike in vivo, where levels decreased. This suggests that in order to prevent side effects, the later after infusion of infliximab the phlebotomy occurs, the better, and that the amount of stored blood transfusion should be consistent with that of blood loss.

Advanced malignant rhabdoid tumor of the ovary effectively responding to chemotherapy: a case report and review of the literature.

BACKGROUND: Malignant rhabdoid tumors (MRTs) are highly malignant neoplasms that consist of both renal and extrarenal subtypes. Primary ovarian cases are extremely rare. We herein describe the third known case of ovarian origin, which effectively responded to combination chemotherapy with ifosfamide, epirubicin, and cisplatin (IEP chemotherapy). CASE: A 19-year-old woman was diagnosed to have stage IIIc primary MRT of the ovary following the resection of tumors. Two months after surgery, an 8 cm-sized pelvic mass and enlarged retroperitoneal lymphnodes were detected. The patient received intravenous tri-weekly IEP chemotherapy. After the second course of chemotherapy, she demonstrated a complete clinical response. CONCLUSION: Although this type of tumor is quite aggressive and chemotherapy is generally not considered to be effective, IEP chemotherapy may be useful in the treatment of MRT of the ovary.